Up until recently, most discussions on improving the US healthcare system focused almost solely on medical care. However, non-medical factors may lead to poor health and poor health outcomes. These factors, called social determinants of health, have only recently started receiving attention, and include (among others):
• Living conditions – condition of housing • Isolation – from family and friends or because of community structure • Availability of public resources – such as transportation
Transportation, or the lack of, has an impact on health and hurts healthcare outcomes. In fact, the impact that transportation has on health is greater than anticipated.
Why is this the case?
Transportation can be a challenge for different people and in various locations:
• Elderly • Disabled • Minority communities • Communities without public transportation • Communities that do not have direct access to specialists or hospitals
It is within these populations that transportation’s impact on individual and population health can most be seen.
Lack of transportation can make it more difficult to get to doctor’s appointments, but it can also reduce compliance with doctor’s instructions, such as filling prescriptions or other instructions.
Missing appointments is another huge problem.
According to the National College of State Legislatures, approximately 3.6 million Americans miss or delay medical appointment simply because they do not have the means to get to the doctor’s office3.
When they are able to get to the doctor, they may not be able to make a trip to the pharmacy or to a testing center to get diagnostics, such as x-rays or blood work, done.
All too often, these missed appointments and deferred care allow the underlying condition to worsen until an Emergency Room visit is needed. And once it is an emergency, transportation in the form of an ambulance, at least, becomes available.
As soon as the patient is discharged, however, the transportation issue rears its ugly head again.
Not having a convenient transportation option makes it difficult to receive prescribed follow-up care, but also patients are, at times, stranded at the hospital because they don’t have ride back home.
The impact of non-compliance with post-discharge instructions is crucial to the healthcare industry, as it often leads to patients not getting better and being readmitted to the hospital. In many states, including Maryland, hospitals are not compensated for readmissions, meaning the cost of the readmission comes out of the hospital’s bottom line.
Medicare and Medicaid will provide reimbursement for transportation to and from medically necessary treatments and doctor’s visits. However, this transportation must be the least expensive option available, which often means a cab.
Many local jurisdictions provide accommodations on public transportation systems (e.g. buses, Call-a-Ride services) for those seeking medical care. These may be anything from including a hospital on a dedicated bus route, operating a deviated route that allows the driver to break from a fixed route by a small distance, or operating a door-to-door paratransit service, which must be scheduled and reserved in advance.
These are all well-intentioned approaches to assisting individuals receive the medical attention they need, and do achieve at least a certain degree of success. However, many challenges remain and trying to adapt public transportation to the specific needs of medical transportation is inefficient and costly.
What is Medical Transportation?
Medical transportation is not simply getting from point A to point B. There is a lot more involved in helping people get to their medical appointments on time. Certain passengers may need extra attention and assistance than a cab can be expected to provide.
Patients who are going to see the doctor may need more assistance and attention than someone going to the supermarket or into town.
For instance, wheelchair-bound patients may need more assistance getting into and out of a vehicle, as well as assistance in being properly secured. Hospital volunteers, at many hospitals, are not permitted to help wheelchair patients get into a vehicle or get them properly secured unless they have been trained for it, specifically.
However, wheelchair patients are not the only patients who may need extra help.
Patients traveling to and from medical visits may be unwell, nervous, or may be experiencing the after-effects of treatment. This can be true of chemotherapy patients.
This need for extra attention is likely to increase the length of time needed for such transport – which means medical transportation needs to have slightly different metrics than general cab transportation services.
Medical transportation should only transport one patient per trip. Using current public transportation systems as transport to medical facilities increases the risk of infecting healthy riders, because patients, who are potentially sick, are using the same system as healthy riders. In addition, it is uncomfortable, not only for sick riders, but also healthy riders to be riding in a closed area with someone potentially infectious.
Some public transit systems openly refuse to transport certain patients, such as those seeking treatment for behavioral issues. This increases the need for medical transport for these patients.
Should public transportation drivers be expected to be trained, or know how, to handle individuals in a behavioral health treatment program?
Some transportations systems that provide transportation to patients will accommodate multiple patients in a single vehicle for financial reasons. While this makes financial and logistic sense, it reduces space available for caregivers and translators – which is important for those who are no longer able to manage their own care, as well as for those who do not speak English.
Medical transport will often include the patient’s family members and/or caregivers – and sometimes the transportation company will not receive advanced notice of this, as determining who will go with the patient to the doctor might not be determined until the day of the appointment.
What does medical transportation need to provide?
• Round trip door-to-door transportation
Non-emergency medical transportation systems need to provide round trip door-to-door transportation. This will go from a patient’s home to the medical facility and back, but also may need to stop at a pharmacy to fill a prescription, or go to a diagnostic center, such as for an X-Ray or MRI.
• Single patient transport
Non-emergency medical transportation should be single patient transport with space in the vehicle for family members and caregivers.
The drivers must have additional skills, including:
• How to perform basic first aid and CPR • Assisting patients from their home to the vehicle • Assisting patients from the vehicle into the doctor’s office, pharmacy, or diagnostic center • Helping secure patients in vehicles • Making sure patient’s belongings are secure (e.g. medical records, medications) • Training in how to deal with patients
The medical transportation service should also help to schedule the doctor’s visits directly, which will require the patient and possibly the provider sharing data with the transport service. Which means the transportation service will need to be HIPAA compliant. In doing this, the transportation service will become the missing link that ensures patients get the medical care they need.
This service can help everyone, especially the following:
• Discharged patients – discharged patients are often readmitted because they are unable to follow post-discharge instruction, do not improve, and wind up being readmitted to the hospital. Transportation is not the only factor contributing to the larger issue of readmission – but it is a key factor.
• Those without convenient access to transportation (e.g. public transportation)– Numerous studies show that individual who rely on public transportation are far more likely to miss necessary medical appointments than those who have transportation2.
• Patients seeking elective outpatient surgery – While such procedures allow patients to go home almost immediately after the procedure, having a transportation service available may alleviate concerns about operating a motor vehicle, or the need to find someone for a ride. This can also address the potential liability issue of driving home from the hospital right after having surgery, no matter how minor.
Medical transport services can serve hospitals and doctors in much the same way that airport shuttle services serve airports.
A medical transport service can also provide additional services, such as bringing a medical provider, a doctor or nurse, to the patient. And perhaps even assisting the patient connect to social services that address the needs that are implicated by social determinants of health.
What benefits can be seen when implementing medical transportation?
A medical transportation service can provide many benefits, including:
• Readmission rates at hospitals will decrease • Greater contact between patients and hospitals will mean more understanding of overall health in people and communities • Improved access to care – especially for those populations at risk, such as the elderly, the disabled, the chronically ill, as well as those who are not served by public transportation • Medical compliance – communities will increase compliance with recognized preventative care, as well as prescribed post-discharge treatment • Enhanced the quality of care – improving compliance means less negative impact on patients, doctors, and hospitals. Instead of focusing on previous medical issues that the patient was unable to follow-up on, the patient will only need to be seen for follow-up or new medical issues.
Medical transportation will also help families who have transportation, but are unable to use it. For instance, many people who care for an elderly parent may live separately, and could find it difficult to transport their parent to and from appointments. This often involves taking time off work, driving to their parent’s home, picking their parent up, driving them to the doctor, waiting with them, driving them back home, and the finally driving back to work. This is a common scenario for such individuals.
A medical transportation service that can pick up and transport the elderly parent to the doctor would allow the adult working child to simply meet the parent at the doctor, and head back to work from there.
Is there a cost for medical transportation?
Medical transportation services are not free to operate. There are two areas of costs:
• Per mile fees for the actual transportation
Typically, this is slightly higher than the per mile fee for taxi cab transportation – which is generally regulated. It’s slightly higher because the driver has a wider skill set.
• Per month, flat rate, cost for non-transportation services
These services include scheduling appointments, tracking post-discharge care instructions and patient compliance with those instruction, as well as IT systems to support that. The IT systems for these services will need to be able to receive the post-discharge instructions, and some additional relevant patient data, from the hospital’s electronic health records (EHR) system.
What other requirements are there for a medical transportation service?
The transportation service will also be required to produce reports on the activity, the value, and customer satisfaction of the medical transportation service.
This can be done by identifying the number of transportation rides given on a monthly basis, the number of riders (patients + family member, caregivers), and the number of miles driven.
In terms of impact, the service should track the number of post-discharge follow-up care appointments kept and whether those patients were readmitted to the hospital.
Customer satisfaction will also need to be measured. Tracking this information provides information on how satisfied customers are with the service, including any aspects that might need to be re-evaluated.
One solution to reducing the cost of the overall healthcare system, while improving the health of patients, is to invest in a medical transportation system – which will also make healthcare in America just a bit more convenient.
1. Traveling towards disease: transportation barriers to health care access, Syed, ST, Gerber BS, Sharp LK, www.ncbi.nlm.nih.gov › PMC4265215 2. The Transportation Barrier, Cronk, Imran, The Atlantic, http://www.theatlantic.com/health/archive/2015/08/the-transportation-barrier/399728/ 3. Non-emergency Medical Transportation: A Vital Lifeline for a Healthy Community, Myers, Amelia, http://www.ncsl.org/research/transportation/non-emergency-medical-transportation-a-vital-lifeline-for-a-healthy-community.aspx